Inquest into the death of Jeremy aka Lawrence Tunkin

39y · Male·acute myocardial ischaemia, coronary artery thrombosis and coronary artery atherosclerosis

Jeremy Tunkin, an Aboriginal man with severe hearing loss, died of acute myocardial infarction while in prison custody. On 6 August 2017, he presented to the medical clinic with what prisoners identified as chest pain, but staff interpreted as throat or shoulder complaints. Communication difficulties due to his deafness likely contributed to misidentification of his complaint. He was discharged after normal observations and returned to his cell. Two days later, he collapsed and died. The coroner found no criticism of the care provided but identified communication barriers as a significant issue. Key lessons: healthcare staff must recognise that cardiac pain can present atypically and be referred to the neck/throat area; heightened vigilance is needed for hearing-impaired patients; appropriate interpreter use and electronic information-sharing between medical and custodial systems are essential to avoid missing critical clinical information.